|
CHG MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION
|
Professional
|
$406.35
|
|
|
Service Code
|
HCPCS 70554 26
|
| Min. Negotiated Rate |
$81.27 |
| Max. Negotiated Rate |
$1,264.96 |
| Rate for Payer: Cash Price |
$110.56
|
| Rate for Payer: Cash Price |
$110.56
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$104.49
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$104.49
|
| Rate for Payer: Fidelis Essential Plan QHP |
$110.30
|
| Rate for Payer: Fidelis Medicare Advantage |
$116.10
|
| Rate for Payer: Fidelis Qualified Health Plan |
$110.30
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$116.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$116.10
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$87.08
|
| Rate for Payer: Healthfirst Medicare Advantage |
$110.30
|
| Rate for Payer: Healthfirst QHP |
$116.10
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$81.27
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$116.10
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$98.68
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$81.27
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$116.10
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$304.76
|
| Rate for Payer: SOMOS Essential |
$304.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$116.10
|
|
|
CHG MRI BRAIN FUNCTIONAL W/O PHYSICIAN ADMNISTRATION
|
Professional
|
$1,686.62
|
|
|
Service Code
|
HCPCS 70554
|
| Min. Negotiated Rate |
$81.27 |
| Max. Negotiated Rate |
$1,264.96 |
| Rate for Payer: Cash Price |
$455.31
|
| Rate for Payer: Cash Price |
$455.31
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$433.70
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$433.70
|
| Rate for Payer: Fidelis Essential Plan QHP |
$457.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$481.89
|
| Rate for Payer: Fidelis Qualified Health Plan |
$457.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$481.89
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$481.89
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$361.42
|
| Rate for Payer: Healthfirst Medicare Advantage |
$457.80
|
| Rate for Payer: Healthfirst QHP |
$481.89
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$337.32
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$481.89
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$409.61
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$337.32
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$481.89
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,264.96
|
| Rate for Payer: SOMOS Essential |
$1,264.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$481.89
|
|
|
CHG MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION
|
Professional
|
$2,502.40
|
|
|
Service Code
|
HCPCS 70555 TC
|
| Min. Negotiated Rate |
$95.49 |
| Max. Negotiated Rate |
$2,234.90 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,876.80
|
| Rate for Payer: SOMOS Essential |
$1,876.80
|
|
|
CHG MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION
|
Professional
|
$477.47
|
|
|
Service Code
|
HCPCS 70555 26
|
| Min. Negotiated Rate |
$95.49 |
| Max. Negotiated Rate |
$2,234.90 |
| Rate for Payer: Cash Price |
$129.09
|
| Rate for Payer: Cash Price |
$129.09
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$122.78
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$122.78
|
| Rate for Payer: Fidelis Essential Plan QHP |
$129.60
|
| Rate for Payer: Fidelis Medicare Advantage |
$136.42
|
| Rate for Payer: Fidelis Qualified Health Plan |
$129.60
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$136.42
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$136.42
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$102.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$129.60
|
| Rate for Payer: Healthfirst QHP |
$136.42
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$95.49
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$136.42
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$115.96
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$95.49
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$136.42
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$358.10
|
| Rate for Payer: SOMOS Essential |
$358.10
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$136.42
|
|
|
CHG MRI BRAIN FUNCTIONAL W/PHYSICIAN ADMNISTRATION
|
Professional
|
$2,979.87
|
|
|
Service Code
|
HCPCS 70555
|
| Min. Negotiated Rate |
$95.49 |
| Max. Negotiated Rate |
$2,234.90 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,234.90
|
| Rate for Payer: SOMOS Essential |
$2,234.90
|
|
|
CHG MRI BRAIN OPEN INTRACRANIAL PX W/CONTRAST MATL
|
Professional
|
$766.05
|
|
|
Service Code
|
HCPCS 70558 TC
|
| Min. Negotiated Rate |
$133.53 |
| Max. Negotiated Rate |
$1,075.28 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$574.54
|
| Rate for Payer: SOMOS Essential |
$574.54
|
|
|
CHG MRI BRAIN OPEN INTRACRANIAL PX W/CONTRAST MATL
|
Professional
|
$667.66
|
|
|
Service Code
|
HCPCS 70558 26
|
| Min. Negotiated Rate |
$133.53 |
| Max. Negotiated Rate |
$1,075.28 |
| Rate for Payer: Cash Price |
$184.01
|
| Rate for Payer: Cash Price |
$184.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$171.68
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$171.68
|
| Rate for Payer: Fidelis Essential Plan QHP |
$181.22
|
| Rate for Payer: Fidelis Medicare Advantage |
$190.76
|
| Rate for Payer: Fidelis Qualified Health Plan |
$181.22
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$190.76
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$190.76
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$143.07
|
| Rate for Payer: Healthfirst Medicare Advantage |
$181.22
|
| Rate for Payer: Healthfirst QHP |
$190.76
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$133.53
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$190.76
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$162.15
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$133.53
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$190.76
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$500.74
|
| Rate for Payer: SOMOS Essential |
$500.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$190.76
|
|
|
CHG MRI BRAIN OPEN INTRACRANIAL PX W/CONTRAST MATL
|
Professional
|
$1,433.71
|
|
|
Service Code
|
HCPCS 70558
|
| Min. Negotiated Rate |
$133.53 |
| Max. Negotiated Rate |
$1,075.28 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,075.28
|
| Rate for Payer: SOMOS Essential |
$1,075.28
|
|
|
CHG MRI BRAIN OPEN INTRACRANIAL PX W/O CONTRAST MATL
|
Professional
|
$2,846.83
|
|
|
Service Code
|
HCPCS 70557
|
| Min. Negotiated Rate |
$142.17 |
| Max. Negotiated Rate |
$2,135.12 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$2,135.12
|
| Rate for Payer: SOMOS Essential |
$2,135.12
|
|
|
CHG MRI BRAIN OPEN INTRACRANIAL PX W/O CONTRAST MATL
|
Professional
|
$2,135.98
|
|
|
Service Code
|
HCPCS 70557 TC
|
| Min. Negotiated Rate |
$142.17 |
| Max. Negotiated Rate |
$2,135.12 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,601.98
|
| Rate for Payer: SOMOS Essential |
$1,601.98
|
|
|
CHG MRI BRAIN OPEN INTRACRANIAL PX W/O CONTRAST MATL
|
Professional
|
$710.85
|
|
|
Service Code
|
HCPCS 70557 26
|
| Min. Negotiated Rate |
$142.17 |
| Max. Negotiated Rate |
$2,135.12 |
| Rate for Payer: Cash Price |
$167.03
|
| Rate for Payer: Cash Price |
$167.03
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$182.79
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$182.79
|
| Rate for Payer: Fidelis Essential Plan QHP |
$192.94
|
| Rate for Payer: Fidelis Medicare Advantage |
$203.10
|
| Rate for Payer: Fidelis Qualified Health Plan |
$192.94
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$203.10
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$203.10
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$152.32
|
| Rate for Payer: Healthfirst Medicare Advantage |
$192.94
|
| Rate for Payer: Healthfirst QHP |
$203.10
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$142.17
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$203.10
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$172.64
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$142.17
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$203.10
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$533.14
|
| Rate for Payer: SOMOS Essential |
$533.14
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$203.10
|
|
|
CHG MRI BRAIN OPEN INTRACRANIAL PX W/O & W/CONTRAST
|
Professional
|
$659.68
|
|
|
Service Code
|
HCPCS 70559 26
|
| Min. Negotiated Rate |
$131.94 |
| Max. Negotiated Rate |
$1,069.30 |
| Rate for Payer: Cash Price |
$175.01
|
| Rate for Payer: Cash Price |
$175.01
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$169.63
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$169.63
|
| Rate for Payer: Fidelis Essential Plan QHP |
$179.06
|
| Rate for Payer: Fidelis Medicare Advantage |
$188.48
|
| Rate for Payer: Fidelis Qualified Health Plan |
$179.06
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$188.48
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$188.48
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$141.36
|
| Rate for Payer: Healthfirst Medicare Advantage |
$179.06
|
| Rate for Payer: Healthfirst QHP |
$188.48
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$131.94
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$188.48
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$160.21
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$131.94
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$188.48
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$494.76
|
| Rate for Payer: SOMOS Essential |
$494.76
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$188.48
|
|
|
CHG MRI BRAIN OPEN INTRACRANIAL PX W/O & W/CONTRAST
|
Professional
|
$766.05
|
|
|
Service Code
|
HCPCS 70559 TC
|
| Min. Negotiated Rate |
$131.94 |
| Max. Negotiated Rate |
$1,069.30 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$574.54
|
| Rate for Payer: SOMOS Essential |
$574.54
|
|
|
CHG MRI BRAIN OPEN INTRACRANIAL PX W/O & W/CONTRAST
|
Professional
|
$1,425.73
|
|
|
Service Code
|
HCPCS 70559
|
| Min. Negotiated Rate |
$131.94 |
| Max. Negotiated Rate |
$1,069.30 |
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,069.30
|
| Rate for Payer: SOMOS Essential |
$1,069.30
|
|
|
CHG MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL
|
Professional
|
$305.66
|
|
|
Service Code
|
HCPCS 77047 26
|
| Min. Negotiated Rate |
$61.13 |
| Max. Negotiated Rate |
$728.20 |
| Rate for Payer: Cash Price |
$82.81
|
| Rate for Payer: Cash Price |
$82.81
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$78.60
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$78.60
|
| Rate for Payer: Fidelis Essential Plan QHP |
$82.96
|
| Rate for Payer: Fidelis Medicare Advantage |
$87.33
|
| Rate for Payer: Fidelis Qualified Health Plan |
$82.96
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$87.33
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$87.33
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$65.50
|
| Rate for Payer: Healthfirst Medicare Advantage |
$82.96
|
| Rate for Payer: Healthfirst QHP |
$87.33
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$61.13
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$87.33
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$74.23
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$61.13
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$87.33
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$229.24
|
| Rate for Payer: SOMOS Essential |
$229.24
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$87.33
|
|
|
CHG MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL
|
Professional
|
$665.28
|
|
|
Service Code
|
HCPCS 77047 TC
|
| Min. Negotiated Rate |
$61.13 |
| Max. Negotiated Rate |
$728.20 |
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$171.07
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$171.07
|
| Rate for Payer: Fidelis Essential Plan QHP |
$180.58
|
| Rate for Payer: Fidelis Medicare Advantage |
$190.08
|
| Rate for Payer: Fidelis Qualified Health Plan |
$180.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$190.08
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$190.08
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$142.56
|
| Rate for Payer: Healthfirst Medicare Advantage |
$180.58
|
| Rate for Payer: Healthfirst QHP |
$190.08
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$133.06
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$190.08
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$161.57
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$133.06
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$190.08
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$498.96
|
| Rate for Payer: SOMOS Essential |
$498.96
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$190.08
|
|
|
CHG MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL
|
Professional
|
$970.94
|
|
|
Service Code
|
HCPCS 77047
|
| Min. Negotiated Rate |
$61.13 |
| Max. Negotiated Rate |
$728.20 |
| Rate for Payer: Cash Price |
$260.48
|
| Rate for Payer: Cash Price |
$260.48
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$249.67
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$249.67
|
| Rate for Payer: Fidelis Essential Plan QHP |
$263.54
|
| Rate for Payer: Fidelis Medicare Advantage |
$277.41
|
| Rate for Payer: Fidelis Qualified Health Plan |
$263.54
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$277.41
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$277.41
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$208.06
|
| Rate for Payer: Healthfirst Medicare Advantage |
$263.54
|
| Rate for Payer: Healthfirst QHP |
$277.41
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$194.19
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$277.41
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$235.80
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$194.19
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$277.41
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$728.20
|
| Rate for Payer: SOMOS Essential |
$728.20
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$277.41
|
|
|
CHG MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL
|
Professional
|
$937.93
|
|
|
Service Code
|
HCPCS 77046
|
| Min. Negotiated Rate |
$55.10 |
| Max. Negotiated Rate |
$703.45 |
| Rate for Payer: Cash Price |
$253.45
|
| Rate for Payer: Cash Price |
$253.45
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$241.18
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$241.18
|
| Rate for Payer: Fidelis Essential Plan QHP |
$254.58
|
| Rate for Payer: Fidelis Medicare Advantage |
$267.98
|
| Rate for Payer: Fidelis Qualified Health Plan |
$254.58
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$267.98
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$267.98
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$200.98
|
| Rate for Payer: Healthfirst Medicare Advantage |
$254.58
|
| Rate for Payer: Healthfirst QHP |
$267.98
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$187.59
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$267.98
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$227.78
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$187.59
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$267.98
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$703.45
|
| Rate for Payer: SOMOS Essential |
$703.45
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$267.98
|
|
|
CHG MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL
|
Professional
|
$662.41
|
|
|
Service Code
|
HCPCS 77046 TC
|
| Min. Negotiated Rate |
$55.10 |
| Max. Negotiated Rate |
$703.45 |
| Rate for Payer: Cash Price |
$178.46
|
| Rate for Payer: Cash Price |
$178.46
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$170.33
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$170.33
|
| Rate for Payer: Fidelis Essential Plan QHP |
$179.80
|
| Rate for Payer: Fidelis Medicare Advantage |
$189.26
|
| Rate for Payer: Fidelis Qualified Health Plan |
$179.80
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$189.26
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$189.26
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$141.94
|
| Rate for Payer: Healthfirst Medicare Advantage |
$179.80
|
| Rate for Payer: Healthfirst QHP |
$189.26
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$132.48
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$189.26
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$160.87
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$132.48
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$189.26
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$496.81
|
| Rate for Payer: SOMOS Essential |
$496.81
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$189.26
|
|
|
CHG MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL
|
Professional
|
$275.52
|
|
|
Service Code
|
HCPCS 77046 26
|
| Min. Negotiated Rate |
$55.10 |
| Max. Negotiated Rate |
$703.45 |
| Rate for Payer: Cash Price |
$74.98
|
| Rate for Payer: Cash Price |
$74.98
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$70.85
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$70.85
|
| Rate for Payer: Fidelis Essential Plan QHP |
$74.78
|
| Rate for Payer: Fidelis Medicare Advantage |
$78.72
|
| Rate for Payer: Fidelis Qualified Health Plan |
$74.78
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$78.72
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$78.72
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$59.04
|
| Rate for Payer: Healthfirst Medicare Advantage |
$74.78
|
| Rate for Payer: Healthfirst QHP |
$78.72
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$55.10
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$78.72
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$66.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$55.10
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$78.72
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$206.64
|
| Rate for Payer: SOMOS Essential |
$206.64
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$78.72
|
|
|
CHG MRI BREAST WITHOUT&WITH CONTRAST W/CAD BILATERAL
|
Professional
|
$1,524.99
|
|
|
Service Code
|
HCPCS 77049
|
| Min. Negotiated Rate |
$88.05 |
| Max. Negotiated Rate |
$1,143.74 |
| Rate for Payer: Cash Price |
$408.65
|
| Rate for Payer: Cash Price |
$408.65
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$392.14
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$392.14
|
| Rate for Payer: Fidelis Essential Plan QHP |
$413.92
|
| Rate for Payer: Fidelis Medicare Advantage |
$435.71
|
| Rate for Payer: Fidelis Qualified Health Plan |
$413.92
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$435.71
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$435.71
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$326.78
|
| Rate for Payer: Healthfirst Medicare Advantage |
$413.92
|
| Rate for Payer: Healthfirst QHP |
$435.71
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$305.00
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$435.71
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$370.35
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$305.00
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$435.71
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$1,143.74
|
| Rate for Payer: SOMOS Essential |
$1,143.74
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$435.71
|
|
|
CHG MRI BREAST WITHOUT&WITH CONTRAST W/CAD BILATERAL
|
Professional
|
$1,084.76
|
|
|
Service Code
|
HCPCS 77049 TC
|
| Min. Negotiated Rate |
$88.05 |
| Max. Negotiated Rate |
$1,143.74 |
| Rate for Payer: Cash Price |
$289.11
|
| Rate for Payer: Cash Price |
$289.11
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$278.94
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$278.94
|
| Rate for Payer: Fidelis Essential Plan QHP |
$294.43
|
| Rate for Payer: Fidelis Medicare Advantage |
$309.93
|
| Rate for Payer: Fidelis Qualified Health Plan |
$294.43
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$309.93
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$309.93
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$232.45
|
| Rate for Payer: Healthfirst Medicare Advantage |
$294.43
|
| Rate for Payer: Healthfirst QHP |
$309.93
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$216.95
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$309.93
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$263.44
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$216.95
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$309.93
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$813.57
|
| Rate for Payer: SOMOS Essential |
$813.57
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$309.93
|
|
|
CHG MRI BREAST WITHOUT&WITH CONTRAST W/CAD BILATERAL
|
Professional
|
$440.23
|
|
|
Service Code
|
HCPCS 77049 26
|
| Min. Negotiated Rate |
$88.05 |
| Max. Negotiated Rate |
$1,143.74 |
| Rate for Payer: Cash Price |
$119.54
|
| Rate for Payer: Cash Price |
$119.54
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$113.20
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$113.20
|
| Rate for Payer: Fidelis Essential Plan QHP |
$119.49
|
| Rate for Payer: Fidelis Medicare Advantage |
$125.78
|
| Rate for Payer: Fidelis Qualified Health Plan |
$119.49
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$125.78
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$125.78
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$94.34
|
| Rate for Payer: Healthfirst Medicare Advantage |
$119.49
|
| Rate for Payer: Healthfirst QHP |
$125.78
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$88.05
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$125.78
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$106.91
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$88.05
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$125.78
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$330.17
|
| Rate for Payer: SOMOS Essential |
$330.17
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$125.78
|
|
|
CHG MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERAL
|
Professional
|
$402.36
|
|
|
Service Code
|
HCPCS 77048 26
|
| Min. Negotiated Rate |
$80.47 |
| Max. Negotiated Rate |
$1,121.82 |
| Rate for Payer: Cash Price |
$109.19
|
| Rate for Payer: Cash Price |
$109.19
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$103.46
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$103.46
|
| Rate for Payer: Fidelis Essential Plan QHP |
$109.21
|
| Rate for Payer: Fidelis Medicare Advantage |
$114.96
|
| Rate for Payer: Fidelis Qualified Health Plan |
$109.21
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$114.96
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$114.96
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$86.22
|
| Rate for Payer: Healthfirst Medicare Advantage |
$109.21
|
| Rate for Payer: Healthfirst QHP |
$114.96
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$80.47
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$114.96
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$97.72
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$80.47
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$114.96
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$301.77
|
| Rate for Payer: SOMOS Essential |
$301.77
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$114.96
|
|
|
CHG MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERAL
|
Professional
|
$1,093.37
|
|
|
Service Code
|
HCPCS 77048 TC
|
| Min. Negotiated Rate |
$80.47 |
| Max. Negotiated Rate |
$1,121.82 |
| Rate for Payer: Cash Price |
$291.86
|
| Rate for Payer: Cash Price |
$291.86
|
| Rate for Payer: Fidelis CHP/HARP/Medicaid |
$281.15
|
| Rate for Payer: Fidelis Essential Plan Aliesa |
$281.15
|
| Rate for Payer: Fidelis Essential Plan QHP |
$296.77
|
| Rate for Payer: Fidelis Medicare Advantage |
$312.39
|
| Rate for Payer: Fidelis Qualified Health Plan |
$296.77
|
| Rate for Payer: Hamaspik Choice Inc Medicaid |
$312.39
|
| Rate for Payer: Hamaspik Choice Inc Medicare |
$312.39
|
| Rate for Payer: Healthfirst CHP/FHP/Medicaid |
$234.29
|
| Rate for Payer: Healthfirst Medicare Advantage |
$296.77
|
| Rate for Payer: Healthfirst QHP |
$312.39
|
| Rate for Payer: MetroPlus Health CHP/HARP/HIV SNP/Medicaid |
$218.67
|
| Rate for Payer: MetroPlus Health Commercial/Exchange/Gold Care/Medicare Advantage |
$312.39
|
| Rate for Payer: MetroPlus Health Essential Plan 1 (Non-Aliessa)/Essential Plan 2 (Non-Aliessa) |
$265.53
|
| Rate for Payer: MetroPlus Health Essential Plan 3 (Aliessa)/Essential Plan 4 (Aliessa) |
$218.67
|
| Rate for Payer: Senior Whole Health Medicare Advantage |
$312.39
|
| Rate for Payer: SOMOS CHP/HARP/Medicaid |
$820.03
|
| Rate for Payer: SOMOS Essential |
$820.03
|
| Rate for Payer: VNS Choice FIDA/MLTC Plus/Medicaid Advantage/Medicare Advantage/Special Needs Dual |
$312.39
|
|
